Category Archives: Centers for Medicare and Medicaid Services (“CMS”)

Subscribe to Centers for Medicare and Medicaid Services (“CMS”) RSS Feed

House Republicans Push Back on Medicare’s New Mandatory Bundled Payment Models

On July 25, 2016, the Centers for Medicare & Medicaid Services (CMS) announced a proposed rule that promises to deliver coordinated, high-quality care for Medicare beneficiaries. The proposed rule (effective July 1, 2017) establishes a mandatory bundled payment program for cardiac care and expands the existing hip and knee bundled payment initiative that launched earlier … Continue Reading

The MACRA Final Rule: The Art of the Transition

On Friday, October 14, 2016, CMS released the much-anticipated final rule (the “Final Rule”) implementing the Quality Payment Program (QPP), mandated by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).  Pursuant to MACRA and the Final Rule, most clinicians will be required to participate in either a new Merit-based Incentive Payment System (MIPS) … Continue Reading

Vermont to Launch a First-in-the-Nation All-Payer System for All Healthcare Providers

As recently reported by Modern Healthcare and other major healthcare news outlets, the Obama administration has granted tentative approval for Vermont to establish an all-payer reimbursement system. If granted final approval, the Vermont All Payer Accountable Care Organization Model (Model) would be effective for five years from January 1, 2017 to December 31, 2022. The … Continue Reading

CMS says to physicians: Pick your pace for MACRA implementation. Physicians say to CMS: Thank you for hearing us.

On April 27, 2016, the Centers for Medicare & Medicaid Services (CMS) issued proposed regulations (Proposed Regs.) as a first step in the implementation of the Quality Payment Program (QPP) provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).  In response to public comments regarding the Proposed Regs., CMS announced on September … Continue Reading

CMS Releases 2017 Medicare Hospital Payment Rates, Penalties for Poor Performers

Earlier this month, the Centers for Medicare & Medicaid Services (CMS) issued a final rule (Final Rule) modifying the Hospital Inpatient Prospective Payment System (IPPS) and Long Term Acute Care Hospital (LTCH) Prospective Payment System (PPS) for fiscal year (FY) 2017. CMS pays acute-care hospitals for services provided to Medicare beneficiaries under the IPPS and … Continue Reading

New Study Finds Medicare Advantage Plans Pay Lower Prices Than Traditional Medicare

A new study by Stanford University researchers finds that Medicare Advantage plans pay lower prices than traditional fee-for-service (FFS) Medicare for most types of hospital admissions. According to the study—published earlier this month in Health Affairs—Medicare Advantage plans pay hospitals about 8% less than FFS Medicare for the same services. These findings may come as … Continue Reading

CMS Oncology Care Model Reforming Payment for Beneficiaries with Cancer

The Center for Medicare & Medicaid Innovation first introduced its Oncology Care Model (OCM) last year. OCM went into effect July 1, 2016, and will run through June 30, 2021. The new multi-payer model is the first CMS physician-led care model aimed at improving cancer treatment for Medicare beneficiaries. CMS hopes to see improvements in … Continue Reading

The Overpayment Rule and the Implied False Claims Theory: “What You Don’t Know Can Still Hurt You”

In 2010, the Affordable Care Act (“ACA”) enacted new rules governing overpayments made by the Medicare and Medicaid programs. Under these rules, providers have 60 days from the date that the overpayment has been identified to return the overpayment or face penalties and treble damages under the False Claims Act (“FCA”).  As described below, recent … Continue Reading

CMS Proposes to Limit Site Neutral Payment Exceptions Applicable to Certain Off-Campus Hospital Departments Following Relocation, Service Expansion, or Certain Ownership Changes

On July 6, 2016, CMS released the 2017 Outpatient Prospective Payment System (OPPS) Proposed Rule which, among other things, implements Section 603 of the Bipartisan Budget Act of 2015.  Despite extensive lobbying efforts by the hospital industry, CMS’ proposed rule would effectively preclude the relocation or the expansion of service lines of existing off-campus provider-based … Continue Reading

CMS 2017 Proposal Reduces Home Health Reimbursements by $180 Million

On June 27, CMS issued a proposal for the 2017 Medicare home health prospective payment system (HH PPS). CMS is proposing a $180 million reduction in 2017. This equates to a 1% drop in reimbursements for home health agencies caring for Medicare beneficiaries. This cut is the next in a series of reductions mandated by … Continue Reading

Maryland Co-Op Claims Risk Adjustment Formula Discriminates Against Smaller Insurers

Maryland’s Evergreen Health Cooperative has filed for an injunction against the federal government to halt payment by the  Consumer Operated and Oriented Plan (co-op) of the $22 million it owes to CareFirst BlueCross BlueShield based on the Affordable Care Act’s risk adjustment formula.  Of the 23 co-ops that launched in 2014, at least half of … Continue Reading

Medicare Makes Changes to the Shared Savings Program to Strengthen Incentives for ACO Care Coordination

On June 6th, the Centers for Medicare & Medicaid Services (CMS) released a final rule shifting how Medicare pays Accountable Care Organizations (ACO) in the Medicare Shared Savings Program.  CMS said the final rule aims to help more ACOs participate in the Medicare Shared Savings Program by improving the payment methodology and providing them with … Continue Reading

CMS Redefines Alternative Payment Models and Offers Option for Merit-Based Incentive Payment System in New Proposed Rule

The Medicare Access and CHIP Reauthorization Act (MACRA) is expected to drastically change how physicians are paid by the Centers for Medicare and Medicaid Services (CMS). Under the proposed rule, physicians will be given the choice between two payment models: alternative payment models (APMs) and the Merit-Based Incentive Payment System (MIPS).  CMS predicts a majority … Continue Reading

New Amendments Grant Failing ACA Co-Op Program Access to Private Capital and Limit Special Enrollment Eligibility

Earlier this month, the Centers for Medicare and Medicaid Services (CMS) passed an interim final rule that amends regulations governing Consumer Operated and Oriented Plans (Co-ops) and tightens restrictions on special enrollment period (SEP) eligibility in the Health Insurance Marketplace. Of the 23 co-op plans established through the Affordable Care Act (ACA), only 11 are … Continue Reading

CMS Grants Extension to Apply for 2015 Meaningful Use Hardship Exemption

The Centers for Medicare and Medicaid Services (“CMS”) continues to work to ensure it is responsive to providers who tried to meet meaningful use standards in 2015 but faced hardships in their efforts. Eligible professionals, eligible hospitals & critical access hospitals (“CAH”) now have until July 1, 2016 to apply to CMS for the Medicare … Continue Reading

CMS Clarifies 60 Day Overpayment Rule

The Department of Health and Human Services’ (HHS) Center for Medicare and Medicaid Services (CMS), is set to publish a final rule that will provide some much needed relief to healthcare providers from the burdens of the so-called 60-Day Overpayment Rule.  The final rule clarifies (1) the 60 day period for refunding overpayments is not … Continue Reading

The Next Rx: New Medicare Part D Initiative Advances Role of Medication Management in Reform

Medicare Part D’s Medication Therapy Management (MTM) program intends to optimize clinical benefits and avoid drug-related problems among eligible beneficiaries. MTM services—involving pharmaceutical and clinical interventions—are offered at no cost to beneficiaries who meet criteria related to annual Part D drug costs, the prevalence of chronic diseases and number of prescription drugs.[1]… Continue Reading

CMS Proposes Mandatory Hospital Participation in New Bundled Payment Program for Hip and Knee Replacements

On July 14th, 2015, the Centers for Medicare and Medicaid’s (CMS) latest proposed rule (Rule) introduced a new alternative payment model. The Rule proposes CMS’ latest alternative payment model known as the Comprehensive Care for Joint Replacement (CCJR) Model. The model is targeted at hospitals that do not currently participate in the CMS Bundled Payments … Continue Reading

CMS Proposes to Modify—but Continues to Stand Behind—its “Two-Midnight” Rule

The “Two-Midnight” rule is a Centers for Medicare and Medicaid Services (“CMS”) billing policy which bases the appropriateness of payments for inpatient services under Medicare Part A versus Part B on provider expectations regarding length of stay.  It has been a source of controversy since its inception in 2013.  In addition to receiving an extended … Continue Reading

Thirteen Years of the Same Rules and Now Big Proposed Changes to the Regulation of Medicaid Managed Care Plans

On June 1, 2015, the Centers for Medicare and Medicaid Services (“CMS”) published a newly proposed rule that would change the way the agency regulates Medicaid managed care plans, the first regulation of its kind since 2002.  The proposed rule seeks to address issues related to the healthcare experience of Medicaid and Children’s Health Insurance … Continue Reading

Proposed Managed Care Rules Leave State Obligations for CHIP Largely Unchanged

The Centers for Medicare & Medicaid Services’ (CMS) proposed rule (“Rule”) that updates Medicaid managed care regulations to reflect changes in the usage of managed care delivery systems, leaves state obligations largely unchanged for the Children’s Health Insurance Program (“CHIP”).[1] Published on June 1, 2015, the proposed rule would codify statute and guidance that has … Continue Reading

There Is Potential Federal Inconsistency Over ACOs

On June 4, 2015, the Centers for Medicare & Medicaid Services issued final revisions to regulations governing accountable care organizations participating in the Medicare Shared Savings Program (“MSSP”). Among them is one explicitly requiring the formation of an ACO as a formal, separate legal entity for governance purposes whenever there are two or more ACO … Continue Reading
LexBlog